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Rx Date /Time <br />11/23/2010 17:39 <br />NOV- 23- 20 10(TUE) IS: 07 9197760678 <br />9197768678 FAIRVIEW DAIRY BAR <br />COUNTY OF LEE <br />APPLICATION TO SERVE ON BOARDS/ /COMMISSIONS <br />P. 001 <br />PAGE 01/01 <br />013 <br />If you are a Lee County citizen interested in serving as a member of one of the County's Advisory Boards, <br />,please complete the form below and mail to Clerk to the Board, Lee County Government Center, PO Box 1968, <br />Sanford, NC, 27331 -1968 or fax to 718 -4631. YOU MUST BE A RESIDENT OF LEE COUNTY TO APPLY, <br />BOARDS AND COMMISSION$ <br />0 <br />Sanford -Lee County Airport Authority <br />Agriculture Advisory Board — <br />Americans with Disabilities Act (ADA) <br />Board of Adjustments (Lee County) <br />Board of Adjustments (Sanford) <br />Board of Equalization & Review _ <br />T Cemetery Board of Trustees <br />CCCC Board of Trustees <br />_ Economic Development Corp <br />_ Fire Advisory Board <br />Environmental Affairs Board <br />Board of Health <br />_ Industry" Facilities & Pollution Control Financing Auth. <br />( <br />NAME: / Earn <br />(�:( t <br />MAILING ADDRESS: 35, <br />HOME PHONE / 9 )? Q6_ 1 437 <br />Jury Commission <br />Library Board of Trustees <br />Mid - Carolina Workforce Development Board <br />Parks & Recreation Commission <br />Planning Board (Lee County) <br />Planning Board (Sanford) <br />Rest Home - Nursing Home Advisory Board <br />Senior Services Advisory Board <br />SoGal Services Board <br />Transportation Advisory Board <br />Juvenile Crime Prevention Council <br />Criminal Justice Partnership Advisory Board <br />C __2 7330 <br />WORK PHONE 1 9 ) O �J S � E -MAIL <br />YEARS LIVING IN (/vV <br />LEE COUNTY: '7 DISTRICT YOU LIVE IN: <br />MALE: ZtEMALE: _ WHITE: ✓BLACK: _ HISPANIC: — NATIVE AMERICAN J OTHER <br />(Information for the purpose of noeurm® o croaa ssotlon of the community) <br />EMPLOYER: <br />OCCUPATION: <br />OTHER MUNICIPAL OR COUNTY BOARDS /COMMITTEES ON WHICH YOU ARE SERVING: C e <br />(Genemily, the Board of Commieeionem deeima to broaden Partkipaucn on 0oardfJCcmmissions for oe much cNZen envoi <br />es poe6IN5: therefore per Board policy, BPPointeas can serve on no more the Pao (2) Boerds/Commissians at a hme. <br />PLEASE USSTTHREE (3) LOCAL PERSONAL REFERENCES AND PHONE NUMBERS: <br />1. . �'j (l(' �(- Ifr2:Pr ( �/T) () 96 - <br />2. <br />3. <br />SIGNATU <br />I <br />DATE: l/ �2 /6) <br />NOV 2 3 20 <br />